Working in mental health – a registrar’s perspective

Dr Peter Byrnes is an ACRRM registrar currently deep into his 12 month Advanced Specialised Training term at Toowoomba Base Hospital’s mental health ward. Here he shares his experiences working in the mental health space, as well as offering some suggestions that may assist you in supporting patients struggling with their mental wellbeing.

Peter’s experience in his AST mental health term so far

Peter currently splits his time between the inpatient unit at Toowoomba Base Hospital, and the community health clinic based in Kingaroy.

“It was very challenging to begin with because there are different patients and supports available at each clinic, and this then requires different decision points. Initially I felt I was doing two jobs badly, but now I’ve settled into the dual role. I often see patients that I’ve already seen in the community and vice versa, so it’s better all round for continuity of care,” he says.

As for the work, Peter says that even though it can be sad and tragic at times, it’s also extremely interesting, allowing him greater freedom when it comes to his consulting sessions.

“You’ve got more time with each patient and you need it, because there’s a lot of complexities in the background. But I think that any opportunity you have to do something that’s a bit different within the general practice field, is something you should grab with both hands,” he says.

Types of patients Peter sees

In his work, Peter says he treats ‘a few distinct categories of patients’, with some crossover in between.

“There are the ones that have a very clear diagnosis like schizophrenia or bipolar affective disorder. They’re either manic or psychotic. With these patients, management is reasonably clear and straightforward medically,” he says.

The other group of patients are ‘more psychology driven’ so there is less you can do medically-speaking.

“This may be patients with mixed anxiety or personality spectrum disorders, and those suffering with depression and stress. These are often the types of patients you’ll see as a GP. You can follow the guidelines when it comes to medications, such as antidepressants. But what the patient really needs is changes to the particular situation that’s driving the mental health concerns, plus a healthy dose of psychotherapy over a long period. It’s all about helping them developing coping strategies they haven’t learnt, or been denied the opportunity to learn.”

Why looking for suicide warning signs is tricky

From his time at the unit, Peter says he’s ‘not convinced there is a lot we can do as doctors to prevent suicide that we’re not already doing’.

“I don’t think a zero suicide rate is achievable, and I’m not even sure if that is a useful focus for public health campaigning,” he explains.

Peter feels it’s very difficult to identify the people you should be most concerned about, plus ‘there’s not a lot we can actually do to influence the choices that people make’. This is especially the case when they’re suffering from reactive depression, a state-driven by circumstances, be it socioeconomic struggles, mental or physical illness.

“The only thing you can do is try to help them change their life around them. Or at least support them in developing skills to cope and adapt. Both of these things are easy to say but deeply difficult to do as these are social, rather than medical problems. But we have to keep working at it.”

What to do if you’re worried a patient might be a suicide risk

Practically speaking, the options available to help a patient you’re worried about centre around ensuring they have a safety net around them, and this often takes the form of a hospital admission.

“Suicide often occurs when people believe the world would be a better place if they were dead. If a patient says ‘I know that if I died, it would be terrible for my kids and family’, that’s reassuring. But if a patient isn’t able to identify things they should continue to live for, and particularly if they have means to take their life, such as firearms in a rural setting, that’s really worrying. If you can’t arrange for someone to look after them that night at home, and they can’t guarantee their safety, then a hospital admission for a short time is a reasonable thing,” Peter says.

It’s also good to be aware of what the hospital inpatient mental health unit can do. Peter says some of the most difficult situations he’s faced with patients concerns unrealistic expectations of what they can provide.

“What we do is provide a safety net, make mental health diagnoses and adjust medication if necessary. This is at best for a couple of days. We tell them the help they need is ongoing psychotherapy with psychologists over time, and it’s going to be hard work. That can be frustrating for both the patient and the doctor admitting them,” he says.

Supporting a patient that has attempted suicide

According to Peter, the first thing to do when helping a patient that has attempted suicide is to be kind, and the next is to show genuine interest.

“People have dreadful things happening in their lives we have likely never experienced. I have no idea what it’s like to be addicted to ice; to have made terrible decisions while under the influence of alcohol; to be an abuse victim; to be homeless; or to have voices either inside or outside my head telling me to do horrible things. What I find helps is to be genuinely curious and ask patients to describe their internal experience, while reassuring them that they’re not a bad person,” he says.

It can be difficult, but Peter says you should avoid jumping in and offer advice straight away because often the things that need to change must come from within the patient themselves.

Looking after your mental wellbeing

Dealing with patients who struggle with mental illness is extremely taxing on GPs, and particularly registrars who may not have had as much experience in this area.

Peter says: “A kind registrar’s first instinct is to give of themselves, both their time and emotional energy. You can keep giving until you’ve got no more and that can be soul-destroying, especially when patients continue with destructive behaviour and nothing you do seems to make a difference. It can grind you down and if you’re not careful, make you angry and disillusioned about mental health patients in general.”

Some of the warning signs of this happening include not wanting to go into work or feeling extreme tension when you think about particular patients. If you find yourself in this position, Peter first recommends taking a deep breath and getting through the session as best you can. Then it might be a good move to have a chat with your supervisor, take a half or full day off, or simply connect with the people you love, for as Peter puts it ‘human contact makes so much difference’.

He says: “Always try to keep in mind that the biggest influence you have is on your own wellbeing right now. So if you’re in a situation where something bad has happened with a patient, take that experience on board, digest it and then come back to yourself and say, ‘Okay, I can’t make the world a better place in the past, but I can in the future, starting with me.’”